Nutrition

IV. TITLE III PROGRAM ADMINISTRATION AND SERVICE DELIVERY

F. QUALITY OF PROGRAM SERVICES PROVIDED -- Part 2

3. Food Safety and Sanitation Practices

The sanitation level of the food production and service facilities and the safety of the food products served are important considerations in meal programs for older persons. Older persons are generally more vulnerable than younger adults to food-borne illnesses; thus, any incidents of food-borne illnesses thatmight occur in the ENP could cause serious problems, and even death, for program participants. The 1992 amendments to the OAA emphasized the importance of safety and sanitation in nutrition projects, requiring nutrition projects to comply with appropriate state or local laws regarding the safe and sanitary handling of food, equipment, and supplies used in the storage, preparation, service, and delivery of meals to older individuals. The evaluation examined whether policies and procedures are in place to ensure that appropriate sanitation practices are followed throughout the production and service process. The evaluation also included MPR interviewer observations of actual kitchen practices. For many of the safety and sanitation issues discussed next, therefore, two types of information are available: (1) interview data; and (2) observational data.

a. SUA Food Safety and Sanitation Policies

Developing and implementing policies and procedures for safe food handling practices represent an important first step in ensuring the safety of food served. Such policies and procedures might be found throughout the aging network, from the SUAs to the actual meal service site or to the delivery of a meal to a homebound participant. Because SUAs are responsible for the overall administration of the ENP within each state, they could be expected to have general food sanitation and safety policies to serve as guidelines for AAAs and nutrition projects. Given the monitoring and assessment requirements for SUAs for activities carried out under their state plans (Section 305(a)(1)(c) of the OAA), it might also be anticipated that these SUAs would have procedures to verify that their policies were indeed implemented throughout the state’s ENP network. We first discuss SUA responses to questions about sanitation and food safety policies and procedures of the SUAs and other agencies under their purview.

The importance of meal site sanitation and food safety inspections is underscored by the number of problems found by the SUAs at the sites when such inspections are made. Recall from subsection D.2 that about 28 percent of the SUAs reported finding sanitation and food safety problems in their last assessments of the AAAs or projects in their state. Seventy-three percent of states require all sites--both ENPproduction and service sites--to be inspected (Table IV.36). In 18 percent of SUAs, only the sites preparing food are required to be inspected. This is of concern, because although it is critical for food production sites to be inspected to ensure that appropriate sanitation standards and food handling procedures are maintained, service sites should also be regularly inspected to ensure the maintenance of appropriate food temperatures and safe handling practices. SUA respondents indicated that states (60 percent) and counties (51 percent) conduct inspections of sites. The facilities were most frequently inspected one or two times per year (78 percent). About 85 percent of the SUAs reported that they had established mechanisms to be sure that inspections are conducted.

About the same proportion of SUAs (75 percent) also require their vendors’ sites to be monitored. SUAs sometimes monitor vendors’ compliance with food safety and sanitation requirements themselves (32 percent) or, more commonly, rely on AAAs for this monitoring (43 percent). About 26 percent, either in conjunction with other monitoring or separately, rely on nutrition projects to monitor vendors’ food production facilities.

Following effective sanitation practices also requires that ENP personnel are trained in sanitation and food safety. About 36 percent of the SUAs reported that there was state certification for food service sanitation in their state (Table IV.36). Sanitation and food safety training was reported as mandatory for different program personnel in a number of states. Such training was most frequently reported as mandatory for food service aides (57 percent), site managers (55 percent), and nutrition project directors (54 percent). Thirty-three percent of the SUAs reported that such training was not mandatory for anyone associated with the ENP at the project or site levels in their state.

TABLE IV.36

SUA FOOD SAFETY AND SANITATION POLICIES

(Percentages)

	SUAs
Sites Required to Be Inspected
All food production and food service sites	73
Only those sites preparing food	18
Neither	7
Other	2
Who Conducts Sanitation Inspections?a
State	60
County	51
Municipality	25
Other	27
No one	2
Times Per Year Each Food Preparation or Handling Site Inspected
Zero	9
One	50
Two	22
Three or more	19
Has Policy or Procedures to Ensure These Inspections Are Conducted	85
Has Regulations Requiring Monitoring of Vendors’ Production Facilities	75
Entity Monitoring Vendors’ Facilities
SUA	32
AAA	43
Nutrition Project	26
Other	33
Mandatory In-Service Training on Food Safety and Sanitation for:
Nutrition project directors	54
Site managers	55
Food service aides	57
Volunteers	43
Drivers	33
Others	19
No one	33
State Certification for Food Service Training Exists	36
Sample Size	55

Source: Elderly Nutrition Program Evaluation, SUA survey.

^a Percentages total more than 100 percent because more than one level of government may conduct inspections.

b. Sanitation and Food Safety Practices at Meal Preparation, Delivery, and Serving Facilities

Actual practices that would affect the sanitation level of the facilities that prepare, deliver, or serve food and the safety of the food served or delivered were an important part of the facility observations conducted by field interviewers. We next discuss a number of different dimensions of safety and sanitation at these sites, such as whether sites use written sanitation procedures, monitor temperatures, train staff, and have regular inspections. Information includes data obtained from the congregate meal site survey and data recorded onto the facility observation form, on the basis of direct observations by MPR interviewers. For most of the discussion, the unit of analysis is the facilities that either prepare, serve, or deliver food to Title III congregate and home-delivered meal program participants. These facilities include congregate meal sites, project-affiliated central kitchens, home-delivered meal distribution staging areas, and other facilities, such as those of vendors or contractors. These results are based on 245 Title III facilities sampled for the evaluation. Some of the results, however, refer only to the kitchens and meal serving areas at the Title III congregate meal sites and include only congregate meal-related operations (not the home-delivered meal program operations, if available through the site). The text clarifies the unit of analysis in each case.

Written Standards and Procedures at Congregate Meal Sites. Managers of congregate meal site kitchens were asked if they had written sanitation and inspection procedures for nine critical activities, such as receiving raw foods or meals, preparing foods prior to cooking, cooking foods, and cooling foods for storage. [ For each activity, site managers could respond "yes, " "no, " or "not applicable. " The latter response was used when a particular activity was not relevant to a site. For example, some meal sites purchase meals from an outside contractor and do not cook food at the meal site; in this case, the interviewer would record "not applicable " for the item on having written policies and procedures for cooking foods. ] ^, [ Respondents at other facilities (n = 102) besides congregate meal sites were also asked whether their organization had written procedures in these nine areas. There was a high percentage of missing data for most of the items. For this reason, we have restricted the analysis to only the congregate meal site kitchens.] The results for all Title III congregate meal sites, and whether congregate meal sites are production kitchens or nonproduction kitchens, are shown in Table IV.37. If we exclude the sites responding "not applicable" from the base, between 60 percent and 81 percent of congregate meal site kitchens reported having written sanitation and inspection procedures for each activity. Such written materials were most commonly available for holding hot foods (81 percent), holding cold foods (81 percent), inspecting food on arrival (79 percent), and storing foods (78 percent). [ The 81 percent figure for cold foods is derived by dividing .64, the percentage of all sites that have written standards or procedures for holding foods cold, by (1 - .21), the percentage of all sites in which this is an appropriate question. ] Written standards and procedures were least frequently available for precooking preparation (60 percent) and for cooking foods (61 percent).

TABLE IV.37

TRAINING AND WRITTEN STANDARDS AND PROCEDURES FOR FOOD SAFETY AND SANITATION, BY TITLE III CONGREGATE MEAL SITE KITCHENS

(Percentages)

	All Kitchens				Production Kitchensa				Other Kitchensb
Processes Subject to Written Standards or Procedures	Yes	No	NA		Yes	No	NA		Yes	No	NA
Receiving Foods	73	19	8		57	21	22		81	18	1
Storing Foods	59	16	25		70	13	17		53	18	29
Preparing Foods Prior to Cooking	29	19	52		66	15	19		9	22	69
Cooking Foods	29	18	53		68	16	16		7	20	73
Holding Hot Foods	70	17	13		75	14	11		68	18	14
Holding Cold Foods	64	15	21		69	12	19		62	16	22
Delivering Hot Foods	45	18	37		60	14	26		36	21	43
Cooling Foods for Storage	35	17	48		66	14	20		19	17	64
Reheating Foods	38	18	44		67	15	18		22	20	58

	All Kitchens		Production Kitchensa		Other Kitchensb
	Yes		Yes		Yes
Provides Training for Food Preparation or Food Handling Staff on Food Safety and Sanitation Issues	92		92		91
Has Staff Member Certified in Food Safety and Sanitation	43		43		43
Staff Member Certifiedc
Site (kitchen) director	28		23		31
Assistant director	8		2		11
Cook	8		22		*
Other personnel	13		8		16
Unweighted Sample Size	157		66		91

Source: Elderly Nutrition Program Evaluation, Meal Site survey, weighted tabulations.

Note: Data on meal sites are from a sample of 158 congregate meal sites that completed the meal site survey.

^a Production kitchens refer to those congregate meal sites in which the nutrition project prepares the meals itself in a project kitchen located at the meal site.

^b Other (nonproduction) kitchens refer to congregate meal sites that receive meals from either an affiliated central kitchen (located off site) or from a caterer, vendor, or contractor.

^c Multiple responses were allowed.

NA = Not applicable.

* = Less than 0.5 percent.

The discussion here focuses on congregate meal sites that prepare meals on site, because these food preparation and handling activities are more applicable to production kitchens than to nonproduction ones. For eight of the nine activities, 80 percent or more of the congregate sites have written standards or procedures in place. For example, 85 percent of congregate site production kitchens have written procedures for storing foods. Noteworthy is the fact that 81 percent of congregate site production kitchens have written procedures for cooking foods. Since the proper cooking of foods, particularly potentially hazardous foods, is a significant and critical procedure for controlling most pathogenic organisms, the finding that about one-fifth of the congregate meal site production kitchens do not have written standards and procedures for cooking food may be an area of concern for potential food safety risk in the ENP.

In general, a greater proportion of production than nonproduction kitchens in congregate sites have written policies or procedures for each of the activities. The exception is for receiving food products or meals. Most differences in the percentages of production and nonproduction kitchens with written standards and procedures for various activities can be explained by the activities that the kitchens undertake.

Staff Sanitation and Food Safety Training at Congregate Meal Sites. Program meal preparation and serving personnel must be adequately trained in sanitation and food safety concepts and practices if adequate standards are to be established and maintained in food production and meal service facilities. About 92 percent of Title III congregate meal site kitchens reported that sanitation and food safety training was provided to their food preparation and food handling staff (Table IV.37). This percentage exceedsthe percentages SUAs reported for mandatory training in different staff classifications. Thus, the meal site kitchens seem to exceed the state mandates for training in sanitation and food safety.

When queried about the topics covered in sanitation and food safety training, respondents noted a wide variety of topics. Topics mentioned with the greatest frequency include food temperatures, temperature monitoring, food handling, hand washing, delivery and storage of food, bacteria and illness control, basic sanitation, personal hygiene, and kitchen cleaning procedures (not shown). Since it is a managerial responsibility to set, implement, and enforce policies and practices, sanitation and food safety knowledge of the kitchens’ management (as a result of certification and the associated training) may be an important factor influencing sanitation practices and food safety in the kitchens. The low proportion of certified personnel (43 percent), however, may be reason for concern regarding ENP food safety over the long term (Table IV.37).

Temperature Monitoring at Congregate Meal Sites. A critical element in maintaining food safety is to keep food products out of the temperature danger zone (between 45 and 140 degrees Fahrenheit) as much as possible, because there is a direct relationship between the cumulative time that foods are in the danger zone and the possible level of contamination from pathogenic organisms. To ensure proper control of food product temperatures, it is important for meal sites to routinely monitor temperatures at critical points in the food production and service cycle.

Most of the Title III congregate meal site kitchens (94 percent) reported that they monitor the temperatures of their food products or ingredients at some point (Table IV.38). [ Caution should be used in interpreting the findings on the percentages of sites monitoring temperatures at specific critical points reported in Table IV.38. Respondents were asked if they monitored food temperatures at the eight points in the food production and service cycle listed under "Temperature Monitoring Points of Food " in Table IV.38. However, unlike the questions on written standards and procedures that allowed respondents to respond "not applicable, " here, for each critical point, respondents were asked only whether they monitored temperatures and were not given the opportunity to report that a particular critical point was not relevant to their site. Thus, for some of the critical points, the percentage of sites monitoring temperatures understates the actual incidence of temperature monitoring because the base includes sites for which the critical point is not relevant.] Congregate meal sites most frequently monitor when food products or meals are delivered to the kitchen (57 percent of all congregate meal site kitchens monitor the temperatures of food products or meals delivered to the meal site). This figure indicates that 43 percent of all congregate kitchens seem to take it for granted that the food products or meals they receive are at the proper temperature needed to ensure safe food service for their clients. Three other monitoring points were mentioned by 30 percent or more of Title III congregate meal site kitchens: (1) when products are in hot-holding units (44 percent of all congregate sites); (2) when food is in serving trays or delivery containers (38 percent); and (3) when products are removed from cooking units (30 percent).

TABLE IV.38

TEMPERATURE MONITORING POINTS BY TITLE III CONGREGATE MEAL SITE KITCHENS

(Percentages)

Monitoring Characteristic	All Kitchens	Production Kitchens	Nonproduction Kitchens
Sites that Monitor Food Temperatures	94	93	94
Temperature Monitoring Points of Food
When received	57	26	74
In hot-holding unit	44	58	37
When removed from cooking unit	30	62	12
During preparation	19	42	7
In refrigerator or freezer	19	30	12
In cold-holding unit	23	27	21
In trays or containers	38	31	42
On plates at congregate sites	2	1	2
Other	3	4	3
Frequency of Checking Food Temperatures
More than once per day	83	65	93
Between once a day and once a week	13	25	7
Between once a week and once a month	2	10	*
Record Temperatures in a Log	92	89	94
Unweighted Sample Size	157	66	91

Source: Elderly Nutrition Program Evaluation, Meal Site survey, weighted tabulations.

Note: Caution should be used in interpreting the findings on the percentages of sites monitoring temperatures. Respondents were asked if they monitored food temperatures at the eight points in the food production and service cycle listed under "Temperature Monitoring Points of Food." However, some of the monitoring points are not applicable to all sites.

^a Production kitchens refer to those congregate meal sites in which the nutrition project prepares the meals itself in a project kitchen located at the meal site.

^b Nonproduction kitchens refer to those congregate meal sites that receive meals from either an affiliated central kitchen (located off site) or from a caterer, vendor, or contractor.

Although it is important to monitor the temperatures of hot foods, it is equally as important to monitor cold food temperatures. Only about one-quarter of the congregate meal site kitchens, however, reported monitoring the temperatures of their cold-holding units, and only about one-fifth reported monitoring food in their refrigerators or freezers. These relatively low monitoring frequencies may indicate that congregate meal site kitchen staff are not as aware of the need to monitor cold food temperatures to maintain food safety as they are of the need to monitor hot temperatures. Only about two percent reported any temperature monitoring on participants’ plates at congregate sites.

Table IV.38 distinguishes findings by whether the congregate meal site is a production kitchen or a nonproduction one. For most of the temperature points, a greater proportion of production kitchens than nonproduction kitchens conduct monitoring. Nevertheless, significant proportions of production kitchens report not monitoring these critical control points. Since there is increasing realization of the importance of temperature monitoring at all critical control points (CCPs) in the food production and service process, having fewer than half of the production kitchens routinely monitoring temperatures at all CCPs is reason for concern.

The majority--74 percent--of the nonproduction congregate meal site kitchens routinely monitor meals or food products when they arrive at the kitchens (Table IV.38). The 26 percent of nonproduction kitchensthat do not routinely monitor both hot and cold product temperatures when products arrive at the kitchens are seemingly relying on the production kitchens or outside vendors to ensure product temperature maintenance and the delivery of safe food. Although products may leave the production kitchens or the vendors’ facilities at the proper temperatures, these temperatures may not be adequately maintained during the transport process.

Temperatures were checked five days per week or more by 83 percent of the congregate meal site kitchens. Ninety-two percent of these kitchens recorded temperatures in a log as a part of their monitoring process. Of those production kitchens that indicated a frequency for reviewing these temperature logs, 33 percent reported a weekly review, 26 percent reported a daily review, and the same percentage reported a monthly review (not shown).

Respondents were asked an open-ended question on the uses of the temperature logs. Of the various uses reported for temperature logs, only one-third seemed to be associated with the regular monitoring of food quality and safety (not shown). More than half of the uses noted seemed to indicate that kitchens kept the logs just for the sake of keeping records or to send them to others in the network or elsewhere--not because these logs were needed as a food sanitation and safety monitoring tool. These kitchens’ failure to recognize the ongoing monitoring purpose of the temperature logs may account for the very low reported daily usage of these logs.

Another area of possible concern was a practice mentioned by some sites of using temperature logs to determine if food temperatures were too low and, if so, to reheat the foods prior to serving them. Reheating and serving foods delivered to congregate sites could be hazardous unless careful records are maintained of the food products’ temperatures and total time-out-of-temperature since they were last heated to a temperature equal to or greater than 140 degrees Fahrenheit.

Procedures for Cold Storage and Hot-Holding Units. [ This and the remaining subsections on sanitation and safety present results for all Title III meal preparation, delivery, and serving facilities--not just Title III congregate meal sites. ] Almost all Title III kitchens (95 percent) reported having one or more refrigerator or freezer units for cold food storage at their site. Because of the importance of proper cold storage temperatures to slow bacterial growth in food products, observations were made of the actual temperatures in freezers and refrigerators at each of the kitchens as well as temperatures recorded in logs. From one to six observations were made at each site, and observations were made of commercial freestanding, noncommercial freestanding, and walk-in refrigerators, as well as freezers and combination refrigerators/freezers. Temperatures were observed on both interior and exterior thermometers. However, interviewers were unable to obtain temperatures for refrigerators and freezers at substantial numbers of the kitchens. [ Usable refrigerator and freezer temperature data were obtained only at approximately 50 percent of the sites.]

The observed interior thermometer refrigerator temperatures ranged from 31 degrees to 55 degrees Fahrenheit, with the most frequently observed temperatures being between 36 and 39 degrees Fahrenheit (47 percent of all observed refrigerator temperatures; Table IV.39). Only three percent had temperatures greater than 45 degrees Fahrenheit. The range of readings for the freezers’ interior temperatures was zero to 30 degrees Fahrenheit; with the median observed temperature being zero degrees Fahrenheit. About 23 percent of the observed freezer temperatures were greater than 5 degrees Fahrenheit. These data indicate that, in general, the cold storage equipment used by kitchens providing food for the ENP provides temperatures appropriate for holding food products safely, assuming foods are properly placed into the refrigerators.

TABLE IV.39

TEMPERATURES OF COLD STORAGE AND HOT-HOLDING UNITS

(Percentages)

		Title III Facilities
Characteristic	All	Production Kitchens	Nonproduction Kitchens
Interior Temperature of Refrigerator, in Fahrenheit (Based on Unit Gauge)
31 to 35 degrees	25	29	12
36 to 39 degrees	47	45	54
40 degrees	14	15	13
41 to 45 degrees	11	9	14
> 45 degrees	3	2	7
Interior Temperature of Freezer, in Fahrenheit (Based on Unit Gauge)
0 degrees	61	67	32
1 to 3 degrees	4	5	2
4 to 5 degrees	12	10	21
6 to 10 degrees	15	11	34
11 to 20 degrees	2	2	2
21 to 30 degrees	6	6	9
Temperatures of Hot-Holding Units, in Fahrenheit (Based on Unit Gauge)
130 degrees or lower	16	1	5
131 to 139 degrees	9	0	2
140 to 149 degrees	3	5	5
150 to 159 degrees	15	6	8
160 to 169 degrees	35	12	18
170 to 179 degrees	5	40	31
180 to 189 degrees	0	21	15
Greater than 189 degrees	17	16	16
Unweighted Sample Size	245	110	135

Source: Elderly Nutrition Program Evaluation, Facility Observation surveys, weighted tabulations.

Hot-holding units for hot foods were also observed. Observers recorded the thermometer readings in from one to four of these units per site, where used. The temperatures most frequently observed ranged from 160 to 169 degrees Fahrenheit (35 percent of hot-holding units); 25 percent of the observed temperatures were under 140 degrees Fahrenheit (Table IV.39). Production kitchens were more likely than nonproduction kitchens to have temperatures above 170 degrees Fahrenheit.

Cleaning and Sanitizing Procedures for Food Contact Surfaces. Even if safe food products are received by a food production facility, foods can easily become contaminated during the preparation process if appropriate cleaning and sanitation procedures are not used at all times. Title III facilities were queried regarding their cleaning and sanitizing practices for areas known to be particularly hazardous for possible food product contamination.

One such area is food contact surfaces, such as cutting boards or countertops. Sites that prepare food (56 percent of all sites) were asked whether, and how often, they clean and/or chemically sanitize food contact surfaces. Virtually all (98 percent) of the sites that prepare food reported cleaning these surfaces with detergent and rinsing them after every use (Table IV.40). Sixty-four percent of the sites that prepare food reported chemically sanitizing food contact surfaces after every use; an additional 28 percent of the sites that prepare food sanitize contact surfaces daily. Six percent sanitize on less than a daily basis, and two percent do not use chemical sanitizing solutions at all. If we use sanitizing after each use as the standard, 36 percent of sites that prepare food (20 percent of all Title III facilities) do not sanitize food contact surfaces after each use and may have potential for food contamination as a result of improper cleaning of surfaces. [ Wooden surfaces (such as wooden cutting boards or baker 's tables) are especially susceptible to contamination if not cleaned and sanitized properly. Forty-three percent of Title III sites that prepare food use wooden surfaces. Ninety percent of sites using wooden contact services (39 percent of the sites that prepare food) clean and chemically sanitize these surfaces after they are used for food preparation. Forty percent of sites that use wooden surfaces (17 percent of the sites that prepare food) clean wooden surfaces with detergent and then rinse them. However, seven percent of sites that use wooden surfaces (three percent of the sites that prepare food) only wipe the surfaces with a damp cloth, not cleaning them with either detergent or sanitizing solutions. ]

TABLE IV.40

CLEANING AND SANITIZING PROCEDURES FOR FOOD CONTACT SURFACES

(Percentages)

Characteristic	Title III Meal Sites/Central Kitchens that Prepare Fooda
Food Contact Surfaces Are Cleaned:
After every use	98
Once a day	2
Never	*
Cleaning Schedule of Food Contact Surfaces Ensured by:b
Site	64
Other	36
Food Contact Surfaces Are Sanitized:
After every use	64
Once a day	28
Other	6
Never	2
Sanitizing Schedule Food Contact Surfaces Ensured by:c
Site	65
Other	35
Nothing is done	*
Procedures for Wooden Surfaces, Such as Cutting Boards or Baker’s Tables, After They Are Used for Food Preparationd
Cleaned with detergent and rinsed	17
Sanitized with chemical solution	39
Wiped with a damp cloth	3
Other	2
No wooden surfaces	57
Unweighted Sample Size	131

Source: Elderly Nutrition Program Evaluation, Facility Observation survey, weighted tabulations.

^a The questions on how contact surfaces are cleaned and sanitized after they are used for food preparation were asked only for sites that prepare food. Fifty-six percent of Title III facilities prepare food at their location. The results shown in the table apply to these sites.

^b Calculated for those that clean food surfaces.

^c Calculated for those that sanitize food surfaces.

^d Percentages exceed 100 percent because multiple responses were allowed.

* = Less than 0.5 percent.

Cleaning and Sanitizing Procedures for Tableware and Kitchen Utensils. All of the facilities were asked about their cleaning and sanitizing procedures for tableware and kitchen utensils. Fifty-seven percent of the Title III facilities indicated that all of their service ware and kitchen utensils are cleaned manually, not by machine (Table IV.41). Forty-three percent use machines--15 percent use machine cleaning only for their service ware and kitchen utensils, and 28 percent use both manual and machine-cleaning procedures. Eighty-six percent of the kitchens with dishwashers (38 percent of all facilities) had hot water sanitizing dishwashing machines. Of the facilities with hot water sanitizing machines, 79 percent (30 percent of all facilities) have a functioning booster heater for the machine. Booster heaters are generally necessary to super-heat the hot water circulating in the facility’s plumbing lines to the minimum temperature of 180 degrees Fahrenheit necessary to sanitize the dishes washed in the machine. Eighty-seven percent of the kitchens with hot water sanitizing dishwashing machines (33 percent of all facilities) reported that their machines have temperature gauges, but only 82 percent of those with gauges (27 percent of all facilities) reported monitoring the water temperatures in the machine. Most kitchens that conduct such monitoring do so once or more per day (66 percent of those with gauges; 22 percent of all facilities).

TABLE IV.41

CLEANING AND SANITIZING PROCEDURES FOR TABLEWARE AND KITCHEN UTENSILS

(Percentages)

Characteristic	Title III Meal Sites/Central Kitchens
Method Used to Clean Tableware and Kitchen Implements
Machine cleaning only	15
Manual cleaning only	57
Both	28
Have Hot Water Sanitizing Dishwasher	38
Have Hot Water Sanitizing Dishwasher with Functioning Booster Heater	30
Have Hot Water Sanitizing Dishwasher with Temperature Gauge	33
Monitor Water Temperature	27
Water Temperature on Hot Water Sanitizing Dishwasher Is Monitored:
More than once a day	11
Once a day	11
Between once a day and once a week	*
Once a week	3
Once a month	2
Have Chemical Sanitizing Dishwasher	5
Dishwasher Wash Cycle Water Temperatures, in Fahrenheit
120 degrees or lower	5
121 to 130 degrees	5
140 degrees	8
141 to 150 degrees	8
151 to 159 degrees	7
160 degrees	4
161 to 169 degrees	4
Greater than 169 degrees	3
Dishwasher Rinse Cycle Water Temperatures, in Fahrenheit
75 degrees or lower	*
111 to 120 degrees	5
121 to 139 degrees	3
140 degrees	3
141 to 150 degrees	5
151 to 160 degrees	5
161 to 170 degrees	2
171 to 180 degrees	10
Greater than 180 degrees	10
Number of Compartments (Tanks) in Sinks for Manual Cleaning
1	3
2	22
3	56
More than 3	5
Method Used to Sanitize for Manual Cleaning
Chemical solution	67
Hot water	16
Nothing	2
Chemical Test Kit Is Available to Check Solution When Manual Cleaning and Chemical Solution Method Is Used	46
Water Is Tested Using Chemical Test Kit:
More than once a day	9
Once a day	16
Once a week	11
Between once a week and once a month	3
Once a month	5
Less than once a month	1
Sinks Have Thermometers Mounted in Each Compartment for Hot Water Sanitation	*
Sinks Have a Functional Booster Heater for Hot Water Sanitation	2
Water Temperature Monitored for Hot Water Sanitation:	4
Check Water Temperatures for Hot Water Sanitation:
More than once a day	3
Once a day	1
Once a month	*
Cleaning Procedures for Tableware and Kitchen Implements Ensured by:
Site	76
Other	21
Nothing is done	3
Manually Cleaning, Wash Sink Water Temperature, in Fahrenheit
75 degrees or lower	*
76 to 100 degrees	6
101 to 110 degrees	14
111 to 120 degrees	26
121 to 139 degrees	14
140 degrees	9
141 to 170 degrees	14
Greater than 170 degrees	1
Manually Cleaning, Rinse Sink Water Temperature, in Fahrenheit
75 degrees or lower	*
76 to 100 degrees	6
101 to 110 degrees	14
111 to 120 degrees	37
121 to 139 degrees	7
140 degrees	9
141 to 170 degrees	8
Greater than 170 degrees	4
Manually Cleaning, Final Rinse Sink Water Temperature, in Fahrenheit
75 degrees or lower	*
76 to 100 degrees	3
101 to 110 degrees	14
111 to 120 degrees	15
121 to 130 degrees	26
131 to 139 degrees	6
140 degrees	7
141 to 170 degrees	10
171 to 180 degrees	2
Greater than 180 degrees	1
Unweighted Sample Size	245

Source: Elderly Nutrition Program Evaluation, Facility Observation survey, weighted tabulations.

* = Less than 0.5 percent.

On the basis of interviewer observation of wash cycle and rinse cycle temperatures, we estimate that the median wash cycle temperature in hot water sanitizing machines is 145 degrees Fahrenheit (Table IV.41). [ Interviewers recorded wash and rinse water temperatures for 81 percent of the facilities with hot water sanitizing dishwasher machines. The weighted distribution of temperatures observed for these facilities was then applied to the full weighted sample of all facilities with hot water sanitizing dishwasher machines to get the estimates for all Title III facilities shown in Table IV.41. ] The median rinse water temperature is 160 degrees Fahrenheit. These low rinse water temperatures could represent a potential food safety risk for the facilities in which they were found.

Manual ware washing, improperly done, can be a potential hazard for food safety. Eighty-four percent of Title III facilities do at least some part of their ware washing manually. Approximately two-thirds of these facilities (56 percent of all facilities) use three-compartment sinks, the most desirable sink configuration for effective sanitizing (Table IV.41). About 26 percent (22 percent of all facilities) use two-compartment sinks, a configuration that combines the rinse and sanitizing processes into one sink. The remainder of the kitchens reported using either single-compartment sinks or sinks with more than three compartments (about eight percent).

When ware washing is done manually, the utensils and service ware must be sanitized by either hot water or a chemical sanitizer in the water. Approximately 80 percent of the facilities that manually wash (67 percent of all facilities) reported that they use chemical sanitizing for their manual ware washing, and 19 percent (16 percent of all facilities) indicated that they used hot water for sanitizing. Unfortunately, two percent of the kitchens indicated that they usually do nothing to sanitize these items. The limited number of kitchens reporting the type of sanitizer used indicated that they use chlorine-containing solutions, as opposed to iodine or quaternary ammonium.

Only 69 percent of those kitchens that said they use chemical sanitizing in their manual ware washing (46 percent of all facilities) indicated that they have chemical test kits available to check the level of sanitizer in the sanitizing solution. Fifty-five percent of the facilities that did have kits (25 percent of all facilities) indicated that they check the water composition at least once a day.

Nineteen percent of the facilities that manually wash serving ware and utensils (16 percent of all facilities) reported that they use hot water as the means of sanitizing in their manual sinks. However, only nine percent of the kitchens using hot water to sanitize (two percent of all facilities) indicated that they have booster heaters for their sinks to raise the temperature of the water in the sanitizing sink to 170 degrees Fahrenheit or more. Fewer than one-fourth of facilities that use hot water for sanitizing in sinks (four percent of all facilities) reported monitoring the water temperature. Those that do so generally monitor the temperatures once or more a day. For those that do not have water temperature boosters in sinks, almost all of them either do nothing or use the hottest water from their sink taps to heat the water for the sanitizing rinse in their sinks, sometimes turning the hot water heater to its highest setting. Even at the highest setting, though, a water heater will not normally heat water to the minimum 170 degrees Fahrenheit required for sanitizing, and even if it did, the water would rapidly cool to a lower temperature once in thesink. Thus, these kitchens may not be sanitizing their service ware and utensils in accordance with generally accepted food service standards, even though they may believe that they are.

Observers measured the temperature of the water in all tanks in the manual wash sinks. Temperatures in the wash tank ranged from 60 to 185 degrees Fahrenheit, with more than half the observed temperatures being 120 degrees Fahrenheit or less. The median temperature of water in the wash tank was about 115 degrees Fahrenheit (Table IV.41). Temperatures in the rinse tank ranged from 60 to 185 degrees Fahrenheit, with most temperatures being between 100 and 120 degrees Fahrenheit. The median temperature of water in the rinse tank was approximately 115 degrees Fahrenheit. At least some of these rinse tanks also served as the final rinse, so the low temperatures observed could pose potential food safety problems for these programs unless chemical sanitizing agents are used in these rinse tanks. If chemical sanitizers are used properly, then there is much less concern about the observed temperatures, since 75 to 120 degrees Fahrenheit is the best temperature range for the most effective sanitizing action of most sanitizers in these rinse tanks. One-quarter of the temperatures, however, were between 120 degrees Fahrenheit (the maximum temperature recommended for the best chemical sanitizing action) and 170 degrees Fahrenheit.

Temperatures in the final rinse tank ranged from 60 to 220 degrees Fahrenheit, with the most frequently observed temperatures being 120 and 130 degrees Fahrenheit. Only five percent of the observed final rinse temperatures were 170 degrees Fahrenheit or higher, as required for hot water sanitizing. The very low observed final rinse tank temperatures underscore the previously noted potential for food safety problems in these programs unless chemical sanitizers are used. There may again be possible temperature problems with sanitizers, however, as only 40 percent of the observed temperatures fell between 70 and 120 degrees Fahrenheit, and 57 percent were between 120 and 180 degrees Fahrenheit.

Protective Devices on the Serving Line. Food is served to participants at 77 percent of all Title III facilities. MPR field interviewers looked to see whether protective devices, such as sneeze guards, are used to help protect food products on the serving line and, if used, are used properly at facilities that serve food. Only one-third of the facilities with serving lines have such devices (not shown). The observers also looked to see if personnel wear disposable gloves when portioning or serving food products. Food service personnel at 77 percent of Title III facilities that serve food wear clean disposable gloves when hand portioning or serving food products. [ In some counties, local ordinances mandate that gloves not be worn. Facilities in these locations were excluded from the tabulations. ]

Hand Washing and Restroom Facilities. Improper hand washing can cause food safety problems. Proper hand washing requires properly equipped hand washing sinks to be readily available to personnel in areas in which frequent hand washing may be required. Field interviewers recorded the location of from one to six hand washing sinks in all of the Title III facilities. They also recorded the sinks’ water temperatures and the availability of soap and hand drying supplies.

Ninety-six percent of Title III facilities have a sink at their facility (Table IV.42). [ The small percentage of facilities that do not have sinks are sites or staging areas for the delivery of meals to home-delivered meal program participants. ] Most of the Title III facilities that have hand washing sinks available to ENP food service personnel have them located either in the food production area or in restrooms available to anyone in the facility. Seventy-five percent of facilities with sinks (72 percent of all facilities) have at least one sink located in a food production area and not in a restroom, and 72 percent (69 percent of all facilities) have at least one sink located in public restrooms. Only a limited number of facilities have sinks in restrooms dedicated for food production personnel (18 percent of facilities with sinks; 17 percent of all facilities). TABLE IV.42HAND WASHING PROCEDURES The sinks are usually always equipped with both hot water (99 percent of sinks) and cold water (99 percent of sinks). Soap is available at 90 percent of the sinks. [ This figure may be lower than 100 percent for two reasons: (1) the facility does not provide soap at the location of the sink; or (2) the facility does provide soap for the sink but, at the time of the interviewer observation, the location had run out of soap. ] Use of single-service towels is the most commonly provided means of hand drying (88 percent of sinks); few of the sinks are equipped with air hand dryers (5 percent).

Ninety-seven percent of Title III facilities have at least one restroom at their location (Table IV.42). Eight percent of Title III facilities have at least one restroom located in the food production or service areas (thus presumably readily accessible to personnel for hand washing). Forty-four percent of facilities have restrooms located near the production and service area on the same floor of the building. Fifty-one percent of facilities locate the restrooms on the same floor as the production and service facilities, but not adjacent to them. Seven percent locate them on a different floor, so they are not readily accessible to food service personnel. Regardless of location, only 59 percent of Title III facilities have hand washing instructions posted in the restrooms to remind staff to wash their hands before returning to the food service areas.

TABLE IV.42

HAND WASHING PROCEDURES

(Percentages)

Characteristic	Title III Meal Sites/Central Kitchens
Have at Least One Sink	96
Locations of Sinksa
Food production area (not in restroom)	72
Restroom in public area	69
Dedicated restroom for food production personnel	17
Other	12
Average Number of Sinks Observed at Kitchens	2.5
Sinks Have:b
Hot water	99
Cold water	99
Soap	90
Single-service towels	88
Air hand dryer	5
Have at Least One Restroom	97
Restroom Facilities Are:a
Within food service/production area	8
Adjacent to food service/production area	44
On the same floor, but not adjacent to food service/production area	51
On another floor	6
Other	1
Hand Washing Instructions Posted in Restroom	59
Unweighted Sample Size	245

Source: Elderly Nutrition Program Evaluation, Facility Observation survey, weighted tabulations.

^a Sums of percentages exceed 100 percent because facilities often have more than one sink or restroom facility, and they may be in different locations.

^b Base for tabulations is "sinks" (n = 662).

Health and Hygiene Practices of Site Personnel. The health and hygiene practices of staff can also have a significant impact on food safety. Field interviewers collected information about the apparent health and hygiene of the food service personnel they observed. These staff included persons delivering meals to congregate sites or to home-delivered meal program participants, as well as site food production and serving staff. Staff were reported as being clean by field interviewers in 98 percent of the Title III facilities visited (Table IV.43). Hair was properly restrained and males were clean shaven (or had well-trimmed moustaches or wore beard guards) in 82 percent of the sites. The lack of hair restraints and of shaving standards in the other 18 percent of sites, however, allows ample opportunity for food contamination from loose hairs or from hair brushing against the prepared food products.

TABLE IV.43

HEALTH AND SANITATION PRACTICES OF FOOD SERVICE PERSONNEL

(Percentages)

Characteristic	Title III Meal Sites/Central Kitchens
Personnel Appear to Be Clean	98
Personnel Have Their Hair Restrained (Including Well-Trimmed Moustaches or Beard Guards)	82
Personnel Wash Their Hands Frequently as They Work	69
Smoking Observed in Food Storage, Production, or Service Areas	4
Unweighted Sample Size	245

Source: Elderly Nutrition Program Evaluation, Facility Observation survey, weighted tabulations.

Also of concern is the reported observation of frequent hand washing in only about 69 percent of the kitchens. [ Observers were asked whether they saw personnel washing their hands frequently as they worked with the food products, as opposed to just wiping their hands on their apron or on a towel, and then going right on with what they were doing--especially when going from one food product to another. ] On the basis of criteria given to the observers, it might be assumed that, in about 30 percent of sites, personnel are more frequently just wiping their hands on their aprons or on towels and then going on with what they are doing, even moving from touching one food product and then another, without washing their hands as needed to prevent contamination or cross-contamination of food products.

Thus, while the overall sanitation practices of most persons working at ENP sites appeared generally good, there is still room for improvement. Such improvement is particularly needed in hand washing practices. Because of the important relationship between hand washing and food safety, improvements in hand washing practices may potentially reduce the food safety risks of these programs.

Food Sources. Another potential source of food safety problems would be use of foods grown, harvested, stored, and/or prepared in unsanitary conditions. Fifty-six percent of Title III facilities prepare food at their locations. Of these facilities, 31 percent (or 17 percent of all facilities) reported using food products from alternative sources, such as food banks, second servings, agricultural crop gleaning, or other such sources, at least once during the past year (not shown). Just two percent of these food preparation facilities reported the use of home-canned foods--foods that should not be used in food services such as the ENP because of the risk of infection from anaerobic bacteria. These data seem to indicate that the food products used in the ENP are almost always obtained from sources that can be expected to provide safe foods to the programs.

Transportation of Food Products and Home-Delivered Meals. Seventy-four percent of the Title III facilities are involved in transporting foods for home-delivered meals. These include central kitchens, congregate meal sites, contractors, or other meal staging areas. In 97 percent of these facilities, the inside of the containers used to transport these meals was observed to be clean and well-maintained(Table IV.44). The inside of the containers used to transport food to congregate meal sites was observed to be clean and well maintained in 98 percent of the nutrition project sites as well. Overall, the kitchens seem to be cleaning and maintaining their transport equipment adequately.

TABLE IV.44

HEALTH AND SANITATION PROCEDURES FOR THE TRANSPORT OF FOOD

(Percentages)

Characteristic	Title III Meal Sites/Central Kitchens
Site Transports Home-Delivered Meals	74
Individual(s) Responsible for Delivering Home-Delivered Mealsa,b
Project staff	40
Contractor	58
Other	3
Vehicle Used to Deliver Mealsa.b
Automobile	18
Truck or van without special equipment	48
Specially equipped truck or van	45
Other	2
Equipment Used to Make Sure Meals Are Delivered in Good Conditiona,b
Insulated containers	73
Styrofoam containers	8
Heated or refrigerated van	8
Cardboard boxes or paper bags	9
Other	13
Nothing	8
Inside of Containers for Transporting Home-Delivered Meals Is Clean and Well Maintaineda	97
Site Transports Food for Congregate Meals	73
Inside of Containers for Transporting Congregate Meals Is Clean and Well Maintainedc	98
Unweighted Sample Size	245

Source: Elderly Nutrition Program Evaluation, Facility Observation survey, weighted tabulations.

^a Calculated only for those facilities that transport food for or are involved in the delivery of home-delivered meals.

^b Sum of percentages exceed 100 percent because facilities may use more than one type of staff or equipment to transport home-delivered meals.

^c Calculated only for those facilities that transport food for congregate meals.

Health Department and Fire Department Inspections. Most of the Title III facilities (83 percent) reported that their site had been inspected by the local health department during the past year. Overall, 86 percent of all Title III facilities were inspected by either the local health department or some other agency during the past year (Table IV.45). About 80 percent of the facilities that were inspected within the past year (68 percent of all facilities) could provide the field interviewer with a copy of their current inspection certificate or report form. Generally, the facilities received good ratings during these most recent inspections. Some caution is needed when interpreting the findings, however, since they are based only on those facilities that made current inspection certificates available to the field interviewers and on the certificates that contained a rating: such facilities represent 52 percent of Title III facilities that were inspected during the past year.

TABLE IV.45

SAFETY AND SANITATION INSPECTIONS

(Percentages)

Characteristic	Title III Meal Sites/Central Kitchens
Health Inspection
Food Service Facility Was Inspected Within Past Year by Local Health Departmenta	86
Current Inspection Certificate Is Available	68
If on a 100-Point Scale, Rating Received
95 to 100 (highest range)	57
90 to 94	18
80 to 89	26
Less than 80 (lowest score)	0
Deficiencies Found in the Past Three Years	44
Facility Has Taken Action to Remedy	41
Remedial Action Was Reported to Inspecting Agency	30
Fire Inspection
Facility Inspected Within Past Year by Local Fire Department	76
Current Inspection Certificate Is Posted or Otherwise Available	29
Unweighted Sample Size	245

Source: Elderly Nutrition Program Evaluation, Facility Observation survey, weighted tabulations.

^a Percentage relates to facilities that answered affirmatively either to a question about whether the food service facility had been inspected within the past year by the local health department or to a question about whether the food service facility had been inspected in the past year by another agency.

Inspection agencies use a variety of rating systems. Most ratings recorded by interviewers were on a 100-point scale, where a higher rating means better performance. Some were descriptive ratings, such as "excellent," "very good," "good," "certificate issued," and "in compliance." Some others simply noted the number of violations. We have 100-point scale ratings for 40 percent of the facilities that were inspected during the past year. About 60 percent of these facilities had a score of 95 or better, and another 18 percent received scores ranging from 90 to 94 during the most recent inspection (Table IV.45). None of the facilities rated on a 100-point scale had a score under 80. [ Twelve percent of the facilities inspected during the past year provided inspection certificates that were converted during analysis to a three-point scale, which ranges from a high rating of 1 to a low rating of 3. More specifically, a 1 rating was given if the facility achieved an "excellent, " "top rating, " "very good " descriptive rating or had "0 violations "; a 2 was given to facilities that achieved "good, " "satisfactory, " "passed, " "certificate issued, " or "incompliance " descriptive rating or had "1 violation "; and a 3 was given to facilities that achieved "conditionally satisfactory " or had "2 or more violations. " Nineteen percent of these facilities received the "excellent or top " rating; the remainder received "good " or "satisfactory " ratings.] Although Title III facilities generally received good ratings on their inspection reports, 51 percent of those inspected (44 percent of all facilities) had one or more deficiencies during the past three health and sanitation inspections. However, 93 percent of those with one or more deficiencies had taken corrective action to remedy these deficiencies by the time of the next inspection, and 74 percent of these had reported this corrective action to the inspecting agency.

Seventy-six percent of the Title III facilities reported being inspected by the local fire department within the past year (Table IV.45). Only 29 percent of these facilities, however, had the inspection certificate posted or otherwise available for the site observer.

c. Incidents of Food-Borne Illness

The major outcome of interest regarding food handling is whether people become sick because of the food served by the meals program. While there have been instances of food-borne illness associated with the ENP, the reported incidence of such outbreaks is relatively low. Table IV.46 summarizes reported data regarding ENP food-borne illness incidents. The more than 400 AAAs surveyed--which represent 60 percent of the AAAs in the country--knew of only six incidents in the past three years of illness associated with the food program. [ Since it is believed that the actual incidence of food-borne illness is much higher throughout the food service industry than the incidence reported, however, the reported incidence of food-borne illness in the ENP is probably less than the actual incidence.] AAAs reported that 175 older persons became ill in the past three years from these six incidents. Not unexpectedly, meat and poultry products were the items associated with the reported food-borne illnesses.

TABLE IV.46

REPORTED INSTANCES OF FOOD-BORNE ILLNESSES RELATED TO TITLE III PROGRAM MEALS IN PAST THREE YEARS

	SUAs	AAAs	Nutrition Projects
Number of Instances	3	6	0
Number of Nutrition Projects Involved	1 Each Instance	1 Each Instance	0
Number of Meal Sites Involved (Number of Occurrences) a	2 (2 Instances); 12 (1 Instance)	0 (1 Instance); 1 (3 Instances); 2 (1 Instance); 12 (1 Instance)	0
Number of People Who Got Sick b	11, 11, 22	3, 12, 22, 48, 88	0
Illness b	Salmonellosis Infection; Staphylococcal Intoxication	Salmonellosis Infection (2); Staphylococcal Intoxication	--
Food Source b	Poultry or Poultry Products (2); Spaghetti (1)	Meat and Meat Products (1); Spaghetti (1); Barbeque (1); Poultry and Poultry Products (1)	--
Years	1992 (1) 1993 (2)	1991 (1) 1992 (3) 1993 (1) 1994 (1)	--
Sample Size	55	393	242

Source: Elderly Nutrition Program Evaluation; SUA, AAA, and Nutrition Project surveys; unweighted tabulations.

^a An AAA reported an instance in which no meal sites were involved that occurred through home-delivered meals.

^b The number of entries is smaller than the number of instances because respondents could not provide more detailed information.

Last Modified: 1/15/2009 11:05:57 AM

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